Summary Report for FSPSAs Initiated During the Report Period Center: 01
This report shows the total number of units/fees for FSPSAs initiated during the report period.
(i.e., start date of service authorization occurs during the report period). This report does not
represent all FSPSAs that overlap the report period. Note that service authorization periods may
range from 1 to 12 months and may vary in intensity from child to child.
FSPSAs starting between: 10-01-15 and 12-31-15 Date of Report: 02-12-16 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 9883 FSPSA's found of which 15 had no frequency modifier field, FORCE FREQ MODIFIER to 0
Services Cpt Code Number of Number of Total Units Total Cost of Avg Fee
Children Records Authorized Auth Services Per Unit Auth
Service Coordination, Class # 01
CASE -CASE NON-TCM CASE MANAGEMENT 2 3 2.311111 $85.5100 $37.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 0.928571 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 94 105 210.300787 $7781.1100 $37.0000
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Subtotal (Total Children Is Unduplicated) 96 109 213.540469 $7866.6200 $36.8400
Screening, Eval, and Assessment, Class # 02
AACIS -92597 AAC INTIAL EVAL BY LICENSED SLP 1 1 2.000000 $205.2600 $102.6300
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 23 28 114.560535 $5556.1800 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 2 0.411111 $19.3600 $47.0900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 2 2 94.066667 $1404.4200 $14.9300
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 4 4 108.031746 $2074.2100 $19.2000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 94.066667 $980.1800 $10.4200
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 94.066667 $2064.7600 $21.9500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 4 4 95.318722 $834.0400 $8.7500
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 91.000000 $733.4600 $8.0600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 4 4 95.318722 $2081.7600 $21.8400
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 2 2 94.066667 $2718.5300 $28.9000
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 91.000000 $5927.7400 $65.1400
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 3.066667 $70.2300 $22.9000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 3 3 91.733333 $2341.9500 $25.5300
AUDE -V5010 ASSESSMENT FOR HEARING AID 8 8 5.616665 $262.8500 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 6 6 4.077777 $487.6900 $119.6000
EVAL -96111 DEVELOPMENTAL EVALUATION 6 11 20.000000 $1000.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 177 201 380.631699 $19031.5800 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 0.002740 $0.2000 $73.9100
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 17 17 15.545434 $1165.9100 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 11 11 7.314480 $548.5900 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 7 7 6.512330 $488.4200 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 17 20 16.822698 $1261.7100 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 20 21 26.015069 $1443.8300 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 182 182 271.149437 $20336.2400 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 79 79 103.754015 $7781.5400 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 46 48 39.097262 $2932.2900 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 224 226 367.338156 $20387.2800 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 110 132 143.163009 $10737.2300 $75.0000
NURS -T1001 NURSING ASSESSMENT 1 1 12.571429 $628.5700 $50.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 0.433333 $22.1200 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 5 5 36.022222 $1838.9300 $51.0500
PDEO -T1024 *PSY-DEV EVAL OUTPATIENT, INITIAL 5 6 0.761644 $114.2700 $150.0300
PSTH -97001 EVAL BY LICENSED PT, INITIAL 11 12 162.728539 $8307.3000 $51.0500
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 3 3 1.961111 $30.5900 $15.6000
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 0.079452 $4.0600 $51.0800
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 25 26 181.260884 $9253.3700 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 2 2 62.083333 $3169.3500 $51.0500
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Subtotal (Total Children Is Unduplicated) 622 1084 2933.650222 $138246.0000 $47.1200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 21 26 112.235856 $561181.5000 $5000.0200
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.252055 $12.6100 $50.0100
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 24 26 89.918635 $4495.9400 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.505556 $36.2100 $71.6200
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 0.654719 $156.6300 $239.2300
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 222 249 159.834198 $7991.6500 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 2 1.133334 $28.3400 $25.0000
CONIF -CONIF CONSULT, FACE TO FACE 168 376 956.915454 $47845.8100 $50.0000
CONIP -CONIP CONSULT, PHONE 7 17 27.533336 $688.3400 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 12 12 99.214286 $2480.3600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1313 1708 12468.203465 $623410.8800 $50.0000
INTR -T1013 INTERPRETER 88 126 851.138289 $42556.9600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1432 2447 16219.993859 $162200.1000 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 58 71 446.076185 $31867.7300 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 3.857143 $220.6300 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 148 212 1571.032230 $112234.5600 $71.4400
PHY -97110HM PT SESSION BY PT ASST 3 3 21.000000 $1200.3600 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 3 3 2.521156 $163.8700 $65.0000
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 4 4 1.599999 $189.6800 $118.5500
SENS -V5050 IN EAR MONAURAL HEARING AID 2 2 0.504110 $119.5600 $237.1600
SENS -V5060 BEHIND EAR HEARING AID
1 1 0.166667 $39.5300 $237.1700
SENS -V5140 BEHIND THE EAR BINAURAL HEARING AI 4 4 1.465830 $695.1900 $474.2600
SENS -V5264 EARMOLD 15 16 100.530593 $1809.5500 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 281 363 3089.890453 $220742.0600 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 7.571429 $433.0800 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 14 14 181.928573 $2525.1700 $13.8800
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 170 208 1313.464002 $656.7300 $0.5000
TRAV -TRAVS Travel by mile 1490 2793 30334.969210 $13499.0700 $0.4500
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Subtotal (Total Children Is Unduplicated) 1626 8690 68064.110622 $1839482.0700 $27.0300
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Total 9883 71211.301313 $1985594.6900 $27.8800
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Number of Children (Unduplicated) With at Least One Authorization 1728